Efficacy and Safety of Anakinra Plus Standard of Care for Patients With Severe COVID-19: A Randomized Phase 2/3 Clinical Trial

Importance

COVID-19 pneumonia is often associated with hyperinflammation. The efficacy and safety of anakinra in treating patients with severe COVID-19 pneumonia and hyperinflammation are still unclear.

Objective

To assess the efficacy and safety of anakinra vs standard of care alone for patients with severe COVID-19 pneumonia and hyperinflammation.

Design, Setting, and Participants

The Clinical Trial of the Use of Anakinra in Cytokine Storm Syndrome Secondary to COVID-19 (ANA-COVID-GEAS) was a multicenter, randomized, open-label, 2-group, phase 2/3 clinical trial conducted at 12 hospitals in Spain between May 8, 2020, and March 1, 2021, with a follow-up of 1 month. Participants were adult patients with severe COVID-19 pneumonia and hyperinflammation. Hyperinflammation was defined as interleukin-6 greater than 40 pg/mL, ferritin greater than 500 ng/mL, C-reactive protein greater than 3 mg/dL (rationale, ≥5 upper normal limit), and/or lactate dehydrogenase greater than 300 U/L. Severe pneumonia was considered if at least 1 of the following conditions was met: ambient air oxygen saturation 94% or less measured with a pulse oximeter, ratio of partial pressure O2 to fraction of inspired O2 of 300 or less, and/or a ratio of O2 saturation measured with pulse oximeter to fraction of inspired O2 of 350 or less. Data analysis was performed from April to October 2021.

Interventions

Usual standard of care plus anakinra (anakinra group) or usual standard of care alone (SoC group). Anakinra was given at a dose of 100 mg 4 times a day intravenously.

Main Outcomes and Measures

The primary outcome was the proportion of patients not requiring mechanical ventilation up to 15 days after treatment initiation, assessed on an intention-to-treat basis.

Results

A total of 179 patients (123 men [69.9%]; mean [SD] age, 60.5 [11.5] years) were randomly assigned to the anakinra group (92 patients) or to the SoC group (87 patients). The proportion of patients not requiring mechanical ventilation up to day 15 was not significantly different between groups (64 of 83 patients [77.1%] in the anakinra group vs 67 of 78 patients [85.9%] in the SoC group; risk ratio [RR], 0.90; 95% CI, 0.77-1.04; P = .16). Anakinra did not result in any difference in time to mechanical ventilation (hazard ratio, 1.72; 95% CI, 0.82-3.62; P = .14). There was no significant difference between groups in the proportion of patients not requiring invasive mechanical ventilation up to day 15 (RR, 0.99; 95% CI, 0.88-1.11; P > .99).

Conclusions and Relevance

In this randomized clinical trial, anakinra did not prevent the need for mechanical ventilation or reduce mortality risk compared with standard of care alone among hospitalized patients with severe COVID-19 pneumonia.

Trial Registration

ClinicalTrials.gov Identifier: NCT04443881.

Clinical validation of risk scoring systems to predict risk of delayed bleeding after EMR of large colorectal lesions

BACKGROUND AND AIMS

The Endoscopic Resection Group of the Spanish Society of Endoscopy (GSEED-RE) model and the Australian Colonic Endoscopic Resection (ACER) model were proposed to predict delayed bleeding (DB) after EMR of large superficial colorectal lesions, but neither has been validated. We validated and updated these models.

METHODS

A multicenter cohort study was performed in patients with nonpedunculated lesions ≥20 mm removed by EMR. We assessed the discrimination and calibration of the GSEED-RE and ACER models. Difficulty performing EMR was subjectively categorized as low, medium, or high. We created a new model, including factors associated with DB in 3 cohort studies.

RESULTS

DB occurred in 45 of 1034 EMRs (4.5%); it was associated with proximal location (odds ratio [OR], 2.84; 95% confidence interval [CI], 1.31-6.16), antiplatelet agents (OR, 2.51; 95% CI, .99-6.34) or anticoagulants (OR, 4.54; 95% CI, 2.14-9.63), difficulty of EMR (OR, 3.23; 95% CI, 1.41-7.40), and comorbidity (OR, 2.11; 95% CI, .99-4.47). The GSEED-RE and ACER models did not accurately predict DB. Re-estimation and recalibration yielded acceptable results (GSEED-RE area under the curve [AUC], .64 [95% CI, .54-.74]; ACER AUC, .65 [95% CI, .57-.73]). We used lesion size, proximal location, comorbidity, and antiplatelet or anticoagulant therapy to generate a new model, the GSEED-RE2, which achieved higher AUC values (.69-.73; 95% CI, .59-.80) and exhibited lower susceptibility to changes among datasets.

CONCLUSIONS

The updated GSEED-RE and ACER models achieved acceptable prediction levels of DB. The GSEED-RE2 model may achieve better prediction results and could be used to guide the management of patients after validation by other external groups. (Clinical trial registration number: NCT03050333.).

Randomised controlled trial on vitreoretinal surgery with and without oral anticoagulants: surgical complications, visual results and perioperative thromboembolic events

BACKGROUND

Vitreoretinal surgery in anticoagulated patients is a challenging situation for vitreoretinal surgeons, who have to choose between being faced with the systemic thromboembolic risks that the interruption of anticoagulation involves, or the intra- and postoperative haemorrhagic risks associated with maintenance of this therapy. So far, no trial has compared, in a prospective and randomized manner, perioperative complications and the visual results associated with continuation or interruption of oral anticoagulant therapy before pars plana vitrectomy (PPV) under retrobulbar anaesthesia. The main objective of this trial is to compare haemostasis-related perioperative complications of PPV in patients maintaining anticoagulant therapy before surgery compared to patients with an interruption in this therapy before surgery.

METHODS

Ninety-six patients will be randomly assigned to either the control group, in whom oral anticoagulant therapy will be interrupted and substituted with subcutaneous heparin according to local clinical practice, or the intervention group in whom oral anticoagulant therapy will not be interrupted before surgery. Patients will be stratified according to the oral anticoagulant they were taking (direct or indirect anticoagulation). They will be followed up for 12 weeks, and the primary outcome, and haemorrhagic complications until 15 days after surgery, will be evaluated.

DISCUSSION

This trial will provide novel information on the possibility of continuing anticoagulant therapy during PPV. The benefits expected from the change in the current surgical management paradigm for anticoagulated patients would be a decreased risk in the incidence of perioperative thromboembolic events and the possibility of performing surgery without delay and without the need for patients to change their usual anticoagulation protocol to the more complex and less safe substitutive therapy.

TRIAL REGISTRATION

Clinical Trials Register EudraCT, 2018-000753-45. Registered on 11 November 2018.

Epidemiological study and genetic characterization of inherited muscle diseases in a northern Spanish region

Background

Inherited muscle diseases are a group of rare heterogeneous muscle conditions with great impact on quality of life, for which variable prevalence has previously been reported, probably due to case selection bias. The aim of this study is to estimate the overall and selective prevalence rates of inherited muscle diseases in a northern Spanish region and to describe their demographic and genetic features. Retrospective identification of patients with inherited muscle diseases between 2000 and 2015 from multiple data sources. Demographic and molecular data were registered.

Results

On January 1, 2016, the overall prevalence of inherited muscle diseases was 59.00/ 100,000 inhabitants (CI 95%; 53.35–65.26). Prevalence was significantly greater in men (67.33/100,000) in comparison to women (50.80/100,000) (p = 0.006). The highest value was seen in the age range between 45 and 54 (91.32/100,000) years. Myotonic dystrophy type 1 was the most common condition (35.90/100,000), followed by facioscapulohumeral muscular dystrophy (5.15/100,000) and limb-girdle muscular dystrophy type 2A (2.5/100,000).

Conclusions

Prevalence of inherited muscle diseases in Navarre is high in comparison with the data reported for other geographical regions. Standard procedures and analyses of multiple data sources are needed for epidemiological studies of this heterogeneous group of diseases.

Achievement of cardiovascular risk factor targets according to sex and previous history of cardiovascular disease in type 2 diabetes: A population-based study

AIMS

The main objective was to assess, using real-practice primary care records, the degree of control of cardiovascular risk factor targets. Records were stratified by the presence of previous history or cardiovascular disease (CVD), and sex differences in the fulfillment profile were analyzed.

METHODS

This is a cross-sectional population-based study conducted in Spain. Type 2 diabetes patients over 20 years old (n = 32,638) were identified from primary care electronic health records, and the following information was extracted: glycated hemoglobin (HbA1c), systolic and diastolic blood pressure (SBP and DBP), LDL and HDL cholesterol levels, triglycerides, BMI and smoking history.

RESULTS

Patients with CVD had worse control of HbA1c than patients without it, (HbA1c < 7% 56.9% vs. 61.2%) but better control of BP (<130/80: 43.5% vs 38.2%) and lipids. In the group without prior CVD history, women had worse control of HbA1c, LDL, HDL, BMI and triglycerides and better control of blood pressure and smoking. These differences were maintained or accentuated in the group with previous CVD.

CONCLUSIONS

Women had poorer control of CV risk factors in both groups, and the sex-gap is accentuated in patients with previous CVD.

Socioeconomic inequalities in cardiometabolic control in patients with type 2 diabetes

BACKGROUND

The aim of this study was to determine if the achievement of control targets in patients with type 2 diabetes was associated with personal socioeconomic factors and if these associations were sex-dependent.

METHODS

This cross-sectional, population-based study was conducted in Spain. Glycated haemoglobin (HbA1c) level and other clinical parameters were obtained from electronic primary care records (n = 32,638 cases). Socioeconomic status was determined using education level and yearly income. Among patients, having their HbA1c level checked during the previous year was considered as an indirect measure of the process of care, whereas tobacco use and clinical parameters such as HbA1c, low-density lipoprotein cholesterol (LDL-c) and blood pressure (BP) were considered intermediate control outcomes. General linear mixed effect models were used to assess associations.

RESULTS

The achievement of metabolic and cardiovascular control targets in patients with type 2 diabetes was associated with educational level and income, and socioeconomic gradients differed by sex. The probability of having had an HbA1c test performed in the previous year was higher in patients with lower education levels. Patients in the lowest income and education level categories were less likely to have reached the recommended HbA1c level. Males in the lowest education level categories were less likely to be non-smokers or to have achieved the blood pressure targets. In contrast, patients within the low income categories had a higher probability of reaching the recommended LDL-c level.

CONCLUSIONS

Our results suggest the presence of socioeconomic inequalities in the achievement of cardiovascular and metabolic control that differed in direction and magnitude depending on the measured outcome and sex of the patient. These findings may help health professionals focus on high-risk individuals to decrease health inequalities.

Incidence of type 1 diabetes mellitus in Navarre stabilized in the last eight years

OBJECTIVES

Incidence of type 1 diabetes mellitus raises a number of controversies. Our study aim was to contribute to answer the following questions: Is incidence of T1DM increasing? Is age at onset of type 1 diabetes mellitus decreasing? Which are the sex differences? Which are the characteristics in adults?

METHODS

A cross-sectional descriptive study using data from a primary source and 3 secondary sources from Navarre collected between 01/01/2009 and 12/31/2016. Annual incidence rates and incidence rate expressed as 100,000 person-years were estimated in the study period by age and sex group. The comparison of the sex and age incidence was made estimating the incidence rate using Poisson's regression methods. The completeness of the register was 96.08%.

RESULTS

During the 8 years analyzed, 428 new cases of type 1 diabetes mellitus were reported (incidence: 8.4/100,000 person-years, 95% CI: 7.6-9.2). Incidence has remained stable and is higher in the group under 15 years old (21.5) than in adults (5.9). Males aged 10-14 years and females aged 5-9 years were the groups with the highest incidence. Incidence then decreased with increasing age. Type 1 diabetes mellitus predominates in males aged 10-45 years, and no changes were seen in age at onset when analized by four-year periods.

CONCLUSION

Navarre shows a very high incidence of type 1 diabetes mellitus in childhood and a low incidence in adulthood. Peak incidence is seen earlier in girls, but the disease predominates in males. Neither incidence nor age at onset have changed.

Insomnia in patients admitted to psychiatric hospital departments

Background. The aim of this study is to estimate the prevalence of insomnia in patients requiring admittance to short-stay hospital psychiatric units. Methodology. A descriptive observational study was designed with the participation of 16 units for brief adult psychiatric hospitalization in Spain. The Athens Insomnia Scale was the instrument used. Results. Four hundred and twenty-five patients were included, with an average value on the global score of the Athens Insomnia Scale of 8.56 (SD: 5.78). The item that obtained the highest average score concerned the presence of waking up during the night, followed by that concerning the time needed to fall asleep. The estimated prevalence of insomnia is 53% (CI 95%). Conclusions. Insomnia is a problem with a high prevalence in psychiatric hospitalization units. The greatest difficulties are found in inducing sleep and staying asleep.

A Scoring System to Determine Risk of Delayed Bleeding After Endoscopic Mucosal Resection of Large Colorectal Lesions

BACKGROUND & AIMS

After endoscopic mucosal resection (EMR) of colorectal lesions, delayed bleeding is the most common serious complication, but there are no guidelines for its prevention. We aimed to identify risk factors associated with delayed bleeding that required medical attention after discharge until day 15 and develop a scoring system to identify patients at risk.

METHODS

We performed a prospective study of 1214 consecutive patients with nonpedunculated colorectal lesions 20 mm or larger treated by EMR (n = 1255) at 23 hospitals in Spain, from February 2013 through February 2015. Patients were examined 15 days after the procedure, and medical data were collected. We used the data to create a delayed bleeding scoring system, and assigned a weight to each risk factor based on the β parameter from multivariate logistic regression analysis. Patients were classified as being at low, average, or high risk for delayed bleeding.

RESULTS

Delayed bleeding occurred in 46 cases (3.7%, 95% confidence interval, 2.7%-4.9%). In multivariate analysis, factors associated with delayed bleeding included age ≥75 years (odds ratio [OR], 2.36; P < .01), American Society of Anesthesiologist classification scores of III or IV (OR, 1.90; P ≤ .05), aspirin use during EMR (OR, 3.16; P < .05), right-sided lesions (OR, 4.86; P < .01), lesion size ≥40 mm (OR, 1.91; P ≤ .05), and a mucosal gap not closed by hemoclips (OR, 3.63; P ≤ .01). We developed a risk scoring system based on these 6 variables that assigned patients to the low-risk (score, 0-3), average-risk (score, 4-7), or high-risk (score, 8-10) categories with a receiver operating characteristic curve of 0.77 (95% confidence interval, 0.70-0.83). In these groups, the probabilities of delayed bleeding were 0.6%, 5.5%, and 40%, respectively.

CONCLUSIONS

The risk of delayed bleeding after EMR of large colorectal lesions is 3.7%. We developed a risk scoring system based on 6 factors that determined the risk for delayed bleeding (receiver operating characteristic curve, 0.77). The factors most strongly associated with delayed bleeding were right-sided lesions, aspirin use, and mucosal defects not closed by hemoclips. Patients considered to be high risk (score, 8-10) had a 40% probability of delayed bleeding.

[Incidence of type 1 diabetes in Navarre, 2009-2012]

BACKGROUND

A north-south gradient for the incidence of type 1 diabetes (DM1) has been described in Europe, with higher incidence in the northern countries. The aim of this study is to describe the incidence data for DM1 in Navarre from 2009-2012, regardless of age at diagnosis, including geographical distribution and age and sex characteristics.

PATIENTS AND METHODS

Prospective study, based on one primary and three secondary sources. Completeness of records was assessed, using the capture-recapture method, at 98.42%. Incidence was compared between different gender and age groups by estimating the incidence ratio using Poisson regression methods. To compare the incidence between the different geographical areas, adjustments were made to the values obtained by the indirect standardization method.

RESULTS

A total of 216 cases were detected (incidence: 8.4/100,000 population/year; 95 % CI: 7.3-9.5). Incidence was higher in children than in adults, although the number of new cases was highest in those aged over 15. The age group with the highest incidence was 10 to 14 years; however, the highest percentage of patients fell in the 15 to 29-year-old group. Incidence was higher in men than in women. The incidence rates in the three southern regions were generally higher than the mean for Navarre.

CONCLUSIONS

Navarre has a very high incidence of DM1 in children and adults aged 15 to 29. DM1 is more common in men and shows some geographic variability.

Streptamer technology allows accurate and specific detection of CMV-specific HLA-A*02 CD8+ T cells by flow cytometry

BACKGROUND

Multimer technology is widely used to screen antigen-specific immune recovery after allogeneic hematopoietic stem cell transplantation (allo-HSCT) as it enables identification, enumeration, phenotypic characterization and isolation of virus-specific T-cells. Novel approaches of multimerization might improve on classical tetramer staining; however, their use as standard monitoring technique to quantify antigen-specific cells has not been validated yet. We have compared two of these available multimeric complexes: pentamer and streptamer to select the best strategy for the incorporation into clinical monitoring practice.

METHODS

CMVpp65^495-503 -specific HLA-A*02:01 CD8⁺ T lymphocytes (CTL^A *^02:01 -CMVpp65^495-503 ) were examined with pentamer and streptamer in peripheral blood cells of 77 healthy volunteers. Quantitative and qualitative analyses were performed to compare the precision and repeatability, sensitivity and accuracy and specificity of both technologies by flow cytometry.

RESULTS

Standard deviation for both techniques was less than 0.05 showing that they are repetitive and precise. Both techniques significantly correlated at high frequencies (r_Spearman  = 0.9422; P < 0.0001) but it was lost at lower levels (<1%) of CTL^A *^02:01 -CMVpp65^495-503 (r_Spearman  = 0.3351; P = 0.1376). Streptamer is more accurate for the detection of CTL^A *^02:01 -CMVpp65^495-503 providing significantly closer values to the theoretical ones (P < 0.0001) as pentamer binds unspecifically to a notable proportion of non-CMV-specific CD8⁺ T-cells.

CONCLUSION

Our results suggest that streptamer multimer provides precise, accurate and specific results to detect CTL^A *^02:01 -CMVpp65^495-503 by flow cytometry. Streptamer multimer can be used not only for the monitoring of early CTL^A *^02:01 -CMVpp65^495-503 reconstitution in immunosuppressed patients following allo-HSCT but also, in conjunction with its reversibility role, for the isolation of CTL^A *^02:01 -CMVpp65^495-503 for its future use in adoptive immunotherapy. © 2016 International Clinical Cytometry Society.

EPB41L3, TSP-1 and RASSF2 as new clinically relevant prognostic biomarkers in diffuse gliomas

Hypermethylation of tumor suppressor genes is one of the hallmarks in the progression of brain tumors. Our objectives were to analyze the presence of the hypermethylation of EPB41L3, RASSF2 and TSP-1 genes in 132 diffuse gliomas (astrocytic and oligodendroglial tumors) and in 10 cases of normal brain, and to establish their association with the patients’ clinicopathological characteristics. Gene hypermethylation was analyzed by methylation-specific-PCR and confirmed by pyrosequencing (for EPB41L3 and TSP-1) and bisulfite-sequencing (for RASSF2). EPB41L3, RASSF2 and TSP-1 genes were hypermethylated only in tumors (29%, 10.6%, and 50%, respectively), confirming their cancer-specific role. Treatment of cells with the DNA-demethylating-agent 5-aza-2′-deoxycytidine restores their transcription, as confirmed by quantitative-reverse-transcription-PCR and immunofluorescence. Immunohistochemistry for EPB41L3, RASSF2 and TSP-1 was performed to analyze protein expression; p53, ki-67, and CD31 expression and 1p/19q co-deletion were considered to better characterize the tumors. EPB41L3 and TSP-1 hypermethylation was associated with worse (p = 0.047) and better (p = 0.037) prognosis, respectively. This observation was confirmed after adjusting the results for age and tumor grade, the role of TSP-1 being most pronounced in oligodendrogliomas (p = 0.001). We conclude that EPB41L3, RASSF2 and TSP-1 genes are involved in the pathogenesis of diffuse gliomas, and that EPB41L3 and TSP-1 hypermethylation are of prognostic significance.

Influence of Age at Diagnosis and Time-Dependent Risk Factors on the Development of Diabetic Retinopathy in Patients with Type 1 Diabetes

Aim. To determine the influence of age at onset of type 1 diabetes and of traditional vascular risk factors on the development of diabetic retinopathy, in a cohort of patients who have been followed up after onset. Methods. Observational, retrospective study. The cohort consists of 989 patients who were followed up after diagnosis for a mean of 10.1 (SD: 6.8) years. The influence of age at diagnosis, glycemic control, duration of diabetes, sex, blood pressure, lipids, BMI, and smoking is analyzed using Cox univariate and multivariate models with fixed and time-dependent variables. Results. 135 patients (13.7%) developed diabetic retinopathy. The cumulative incidence was 0.7, 5.9, and 21.8% at 5-, 10-, and 15-year follow-up, respectively. Compared to the group with onset at age <10 years, the risk of retinopathy increased 2.5-, 3-, 3.3-, and 3.7-fold in the groups with onset at 10-14, 15-29, 30-44, and >44 years, respectively. During follow-up we also observed an association between diabetic retinopathy and HbA1c levels, HDL-cholesterol, and diastolic blood pressure. Conclusion. The rate of diabetic retinopathy is higher in patients who were older at type 1 diabetes diagnosis. In addition, we confirmed the influence of glycemic control, HDL-cholesterol, and diastolic blood pressure on the occurrence of retinopathy.

Low Serum Levels of Prealbumin, Retinol Binding Protein, and Retinol Are Frequent in Adult Type 1 Diabetic Patients

Aim. To determine the serum prealbumin (PA), retinol binding protein (RBP), and retinol levels in adult patients with type 1 diabetes (T1D) and to analyze some factors related to those levels. Methods. A total of 93 patients (47 women) were studied. Age, gender, BMI, duration of diabetes, chronic complications, HbA1c, lipid profile, creatinine, albumin, PA, RBP, and retinol were recorded. High and low parameter groups were compared by Mann-Whitney U and χ² tests. Correlation between parameters was analyzed by Spearman's test. Odds of low levels were analyzed by univariate logistic regression and included in the multivariate analysis when significant. Results. 49.5%, 48.4%, and 30.1% of patients displayed serum PA, RBP, and retinol levels below normal values, respectively. A high correlation (Rho > 0.8) between PA, RBP, and retinol serum levels was found. Patients presenting low levels of any of them were predominantly women, normal-weighted, and with lower levels of triglycerides and serum creatinine. No differences in age, macrovascular complications, duration of diabetes, or HbA1c values were observed when comparing low and normal parameter groups. Conclusion. Low serum levels of PA, RBP, and retinol are frequent in T1D adult patients. This alteration is influenced by female sex and serum creatinine and triglyceride levels.

[Prognostic value of Onodera's index in colorectal cancer survival]

BACKGROUND

Onodera's prognostic nutritional index (OPNI), which is calculated using total lymphocyte count and serum albumin level, has been used as a marker of nutritional status, with its potential prognostic value in colorectal cancer having recently been postulated in Japan and China. There is still no data on the predictive value of OPNI in a Western population.

PATIENTS AND METHODS

A consecutive case series of 207 patients scheduled for colorectal cancer resection with curative intent was reviewed. Pre-treatment OPNI was calculated using the formula: [10 x serum albumin (g/dl) + 0.005 x lymphocytes/mm²]. OPNI values under 40 were considered low. Univariate and multivariate analysis were performed on survival curves, comparing cases with OPNI values less than, equal to or greater than 40 (Cox model, stepwise), in the overall series and in pTNM stage II.

RESULTS

The median for clinical follow-up was 81 months (interquartile range 60-96). Twenty-six patients (12.6%) had a low OPNI (≤ 40). In the multivariate analysis, patients with low OPNI showed less favourable survival curves, both in the overall series: [p <0.001; HR = 3.16; 95% CI = 1.67-5.94] and in the 78 cases in pTNM stage II: [p <0.004; HR = 4.36; 95% CI = 1.61-11.76].

CONCLUSIONS

A low pre-treatment OPNI (<40) has an independent, unfavourable predictive value on survival in European patients with resected colorectal cancer, both in the overall series and in pTNM stage II.

Spontaneous parkinsonism is associated with cognitive impairment in antipsychotic-naive patients with first-episode psychosis: a 6-month follow-up study

There is now growing evidence that parkinsonism and other extrapyramidal signs are highly prevalent in patients with first-episode psychosis who have never been exposed to antipsychotic drugs. However, the neurocognitive correlates of parkinsonism in this population remained to be clarified. A sample comprising 100 consecutive drug-naive patients with first-episode psychosis were enrolled on the study and followed up for 6 months. Seventy-seven completed assessments at 3 time points (baseline, 1 mo, and 6 mo), involving clinical and cognitive examinations and a specific assessment of motor abnormalities. The Simpson-Angus Scale (SAS) was used for the assessment of extrapyramidal signs, and each motor domain was evaluated with a standard assessment scale. Linear mixed models were built to explore the longitudinal relationships between parkinsonism scores and cognitive impairment. Parkinsonism scores showed significant strong longitudinal associations with deficits in memory, executive functioning, and attention. Spontaneous parkinsonism (total SAS score and hypokinesia and rigidity subscores at baseline) showed high 6-month predictive values for cognitive impairment. In addition, they also had high predictive values for neurologic soft-sign abnormalities but not for dyskinesia, akathisia, and pure catatonic abnormalities. No predictive value was found for glabella-salivation or tremor subscores on the SAS scale. These results emphasize the relevance of the assessment of parkinsonism signs prior to starting to administer antipsychotic drugs, as core manifestations of psychotic illness with a high predictive value for cognitive impairment.

Influence of age at diagnosis on glycaemic control evolution in patients with type 1 diabetes

AIM

The objective of this study was to describe the relationship between age at onset, with no age limits, and glycaemic control evolution from the time of onset in patients with type 1 diabetes (T1D).

METHODS

This observational retrospective follow-up study included 716 patients with T1D onset between 1990 and 2008 treated at the Navarre Hospital Complex. The mean (SD) follow-up lasted 10.1 (5.3) years. Information on their HbA(1c) levels was collected at onset and every year thereafter. Generalized additive mixed models and linear models were used, with patients' annual HbA1c levels as the response variable and the number of years since onset together with age at onset as covariates.

RESULTS

The evolution of glycaemic control is not linear and differs across all age groups. Children reach their highest values in adolescence, while patients with onset at ages 10-15 years stabilize their HbA(1c) values after 7 or 8 years. In adults, it is notable that an age of onset ≥ 45 years is associated with the worst control.

CONCLUSION

A non-linear increase in HbA(1c) levels can be observed from the time of T1D diagnosis, with significant differences across all age groups.

Determinants of patient satisfaction with care in a Spanish oncology day hospital and its relationship with quality of life

OBJECTIVE

This study evaluates satisfaction with care (SC) in cancer patients treated at a Spanish day hospital to identify SC determinants and assess the relationship between SC and quality of life.

METHODS

One hundred seventy-six patients with different tumour sites and disease stages completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the Cancer Outpatient Satisfaction with Care questionnaire for chemotherapy (OUT-PATSAT35 CT), the Oberst patients' perception of care quality and satisfaction scales, and an item on intention to recommend the hospital. Frequencies in the SC instruments, Spearman correlations between each scale of the OUT-PATSAT35 CT and overall satisfaction and between the subscales of OUT-PATSAT35 CT and of QLQ-C30 were calculated, and the determinants of patients' SC were calculated through multivariate regression models.

RESULTS

Satisfaction with care was high: mean scores were >70 in all OUT-PATSAT35 CT areas except doctor availability and environment. These scores were in line with the other SC instruments. Correlation with overall satisfaction was high and statistically significant (p < 0.01) for all subscales, especially for the nurses domain, which also had higher SC scores. Correlations between the EORTC QLQ-C30 and the OUT-PATSAT35 CT were low (≤ 0.35). Younger patients and those with breast cancer showed significantly lower satisfaction in most subscales. Unmarried patients and patients that had undergone surgery reported lower satisfaction only in specific subscales.

CONCLUSIONS

Satisfaction with care among cancer patients treated at the day hospital is high. Nurses play a key and successful role. Age and tumour location revealed stronger relationships with SC. Correlations between SC and quality of life indicate that these concepts are complementary.

[Neurological complications associated with ultrasound-guided interscalene and supraclavicular block in elective surgery of the shoulder and arm. Prospective observational study in a university hospital]

OBJECTIVES

The incidence of postoperative neurological symptoms after performing interscalene block varies between 4 and 16%. The majority of cases are resolved spontaneously within a year, but some patients have their symptoms permanently. Our objective was to assess the incidence of postoperative neurological symptoms after performing the ultrasound-assisted interscalene and supraclavicular anaesthetic blocks.

MATERIAL AND METHODS

A prospective and observational study was conducted on consecutive patients who had undergone upper extremity surgery with an interscalene or supraclavicular block as an isolated technique, or as a complement to general anaesthesia. Seven days after the intervention, a telephone interview was conducted that focused on the detection of neurological symptoms in the operated limb. Further serial interviews were conducted on patients with symptoms (after the first, the third and the sixth month, and one year after surgery) until resolution of symptoms. Neurological evaluation was offered to those patients with persistent symptoms after one year.

RESULTS

A total of 121 patients were included, on whom 96 interscalene blocks and 22 supraclavicular blocks were performed. Postoperative neurological symptoms were detected in 9.9% (95% CI, 5-15%) of patients during the first week. No significant differences were observed between interscalene (9%) and supraclavicular block (14%). After 3 months the symptoms persisted in 9 patients (7.4%), with symptoms remaining in 4 patients (3.3%) after 1.5 years. Electromyogram was performed on 3 patients who tested positive for nerve damage.

CONCLUSIONS

A high incidence of postoperative neurological symptoms was observed, and a worrying percentage of permanence of them. There were no significant differences in incidence according to the type of block, or any features of the patient or the anaesthesia technique that were associated with the incidence of these symptoms, except a marginal relationship with age. These complications must be clearly explained to the patients before performing these blocks.

[Differences by age and gender in the incidence of type 1 diabetes in Navarre, Spain (2009-2011)]

OBJECTIVE

To determine the incidence of type 1 diabetes in Navarre, irrespective of age, from 2009 to 2011, and its characteristics at onset by age and gender.

METHOD

A descriptive cross-sectional study was conducted. Data were obtained from one primary and three secondary sources. Poisson regression models were used to analyze differences in incidence rates among age groups and between male and female patients.

RESULTS

We detected 167 new cases (incidence: 8.7/100,000 inhabitants-year; 95%CI: 7.4-10.1). The incidence was higher in children than in adults and was highest in the group aged 10-14 years. The incidence was higher in males than in females. The incidence increased with age in boys under 15 years but not in girls.

CONCLUSIONS

The incidence of type 1 diabetes in children and young adults in Navarre is among the highest in Europe. Differences were found by age and gender.

Variability in the detection and monitoring of chronic patients in primary care according to what is registered in the electronic health record

BACKGROUND

The electronic health record (EHR) allows a detailed study of the primary care consultations and assessment of variability among physicians regarding the implementation of practices for prevention, detection and monitoring of chronic diseases.

OBJECTIVES

To describe the variability in the detection and surveillance of chronic conditions in primary care.

METHODS

Review of the medical records maintained by 1685 primary care physicians in the Basque Health Service. Estimation of age and sex standardized rates of compliance with evidence-based recommendations and the systematic component of variation (SCV).

RESULTS

Compliance with screening recommendations varied from 14.2% for chronic obstructive pulmonary disease (COPD) to 37.2% for hypercholesterolaemia of the at-risk populations. Variability between Primary Care Units (PCUs) was low (SCV(5) (-95) < 0.10) for high blood pressure, hypercholesterolaemia and diabetes and high (SCV(5) (-95) ≥ 0.20) for COPD. Based on the EHR registries, recommendations were followed to in at least 50% of relevant patients according to only 10 of the 44 good care practice (GCP) criteria. For 16 of the GCP criteria, the EHR data indicated compliance to the recommendations in <25% of patients diagnosed.

CONCLUSIONS

EHR data indicate that some of the preventative care practices recommended to detect chronic problems in primary care are unevenly implemented across PCUs. Notably, there is less variation in the case of conditions for which evidence-based clinical practice guidelines have been published. The level of monitoring is inadequate for all the conditions studied; particularly in those in which it is less evident that primary care is the right level of the health service to provide this care.

Duration of untreated negative and positive symptoms of psychosis and cognitive impairment in first episode psychosis

BACKGROUND

Duration of untreated psychosis (DUP) has been significantly associated with poor clinical and social outcomes in First Episode Psychosis (FEP) patients, but an association with cognitive outcomes has not been clearly established.

METHOD

Seventy-seven consecutively admitted, drug-naïve patients with FEP were assessed at baseline and at 1month and 6months. Underlying dimensions of DUP (general prodrome and positive, negative and disorganisation symptoms) were assessed using the Symptom Onset in Schizophrenia (SOS) inventory (Perkins et al., 2000). To assess the effect of DUP on the neuropsychological status of the patients, a linear mixed-effect model was fitted to each neuropsychological dimension. These models included a dichotomised version of DUP (short versus long duration) as a fixed effect, several adjusting variables to account for patient differences, and a random effect to incorporate the longitudinal structure of the data.

RESULTS

Patients with a short duration of untreated negative symptoms (DUNS) or a short duration of untreated positive symptoms (DUPS) outperformed patients with a long duration of untreated symptoms on memory tasks and a pre-attentional visual task but not on measures of verbal fluency, attention, reaction time, visual processing and executive functions.

CONCLUSIONS

This study provides additional support for an early intervention to shorten DUP to facilitate a better outcome in memory and attentional domains of FEP patients.

Red blood cell distribution width, multimorbidity, and the risk of death in hospitalized older patients

We aimed to assess the association between red blood cell distribution width (RDW) and mortality in patients enrolled by a Geriatric Department. One hundred twenty-two patients were followed up during 5 years. The primary end point was all-cause mortality, and hazard ratios were estimated using a Cox proportional hazard model. Higher RDW values were strongly associated with an increased risk of death. Survival curves across RDW quartiles were statistically different according to the log-rank test (p = 0.017). The first quartile presented higher probability of survival compared to the last one. The gradient from lower to higher risk across quartiles was clear both in the 5-year mortality risk and in the mortality rate per 100 person-years, which ranged from 18.9 to 42.6. However, in the Cox regression model after adjusting for age, severity, and other factors, excess risk was only observed in the highest RDW quartile, with a hazard ratio of 2.24 (CI(95%) 1.13-4.42) vs the first quartile. RDW is a good predictor of mortality in hospitalized older adults beyond those with cardiovascular risk factors, and it could serve as an integrative measure of multiple clinical and subclinical processes simultaneously occurring in complex patients.

[Usefulness of IPC continuous monitoring in shunt dysfunction]

Shunt dysfunction is a common situation in neurosurgery. Often symptoms, physical examination and radiology are not enough to set a diagnosis. ICP continuous monitoring is a safe and reliable tool that provides valuable information about CSF dynamics in these patients. Not only quantitative analysis is needed but also a qualitative one that enables pathological waves identification, because high amplitude B waves are strongly related to shunt dysfunction. In this paper experience about ICP continuous monitoring in patients with shunt dysfunction suspect is presented. Quantitative and qualitative data analysis led to a correct diagnosis, improving all the patients treated according to this criterion. An intraparenchymatous Camino® sensor and neuroPICture software (developed by first author) for data collection and graphic representation were used. Complications related to monitoring were absent and graphics obtained useful for qualitative analysis.

Cannabis and first-episode psychosis: different long-term outcomes depending on continued or discontinued use

OBJECTIVE

To examine the influence of cannabis use on long-term outcome in patients with a first psychotic episode, comparing patients who have never used cannabis with (a) those who used cannabis before the first episode but stopped using it during follow-up and (b) those who used cannabis both before the first episode and during follow-up.

METHODS

Patients were studied following their first admission for psychosis. They were interviewed at years 1, 3, and 5. At follow-up after 8 years, functional outcome and alcohol and drug abuse were recorded. Patients were classified according to cannabis use: 25 had cannabis use before their first psychotic episode and continuous use during follow-up (CU), 27 had cannabis use before their first episode but stopped its use during follow-up (CUS), and 40 never used cannabis (NU).

RESULTS

The 3 groups did not differ significantly in symptoms or functional outcome at baseline or during short-term follow-up. The CUS group exhibited better long-term functional outcome compared with the other 2 groups and had fewer negative symptoms than the CU group, after adjusting for potential confounders. For the CUS group, the effect size was 1.26 (95% confidence interval [CI]=0.65 to 1.86) for functional outcome and -0.72 (95% CI=-1.27 to -0.14) for negative symptoms. All patients experienced improvements in positive symptoms during long-term follow-up.

CONCLUSION

Cannabis has a deleterious effect, but stopping use after the first psychotic episode contributes to a clear improvement in outcome. The positive effects of stopping cannabis use can be seen more clearly in the long term.

Can positive family factors be protective against the development of psychosis?

Genetic and environmental factors are both involved in the aetiology of psychotic disorders. The aim of this study was to assess if positive and negative environmental factors, together with psychotic family antecedents, are associated with the recent development of psychosis. We also investigated the interactions between family history of psychosis and positive and negative family environment. The sample comprised 110 children and adolescents, who had suffered a first psychotic episode and 98 healthy controls. All subjects were interviewed about their socioeconomic status, family history of psychosis and family environment (Family Environment Scale, FES). Early onset psychosis was significantly associated with a family history of psychosis. Family environment was perceived as more negative and less positive among patients than among controls. A negative family environment increased the risk of psychosis independently of the family history of psychosis. However, there was a significant protective effect of a positive family environment for persons with a family history of psychosis. This effect was not seen in subjects without a family history of psychosis. Therefore, our results support the importance of considering both family history of psychosis and family environment in the early stages of psychosis.

Mortality in small geographical areas and proximity to air polluting industries in the Basque Country (Spain)

OBJECTIVES

To study the association between proximity to air polluting industrial facilities and mortality in the Basque Country (Spain) in the 1996-2003 period.

METHODS

A cross-sectional ecological study with 1465 census sections (CS) as units of analysis with a mean population of 1257 inhabitants. Association of CS mortality with proximity of industries of the European Pollutant Emission Register was studied by type of industrial activity and adjusted for social deprivation. Two distance thresholds (1 km and 2 km) were used as proxies for exposure in a 'near versus far' analysis. Causes of mortality studied were: all causes; tracheal, bronchial, and lung cancer; haematological tumours; ischaemic heart disease; cerebrovascular diseases; chronic diseases of the lower respiratory tract; and breast cancer (in women). Poisson's generalised linear mixed models (GLMM) with two random effects (heterogeneity and structured spatial variability) were used in a fully Bayesian environment.

RESULTS

Men living in sections within 1 km from energy production industries had greater mortality from tracheal, bronchial, and lung cancer [CI(90%) 6% to 53%] as compared with people living further. Women had greater mortality from ischaemic heart disease [CI(90%) 1% to 17%] and respiratory illness [CI(90%) 1% to 24%] within 2 km from metal-processing industries. On the contrary, within the 1 km buffer from mineral industries, mortality was lower for all causes [CI(90%) -20% to -6%] and for ischaemic heart disease [CI(90%) -40% to -10%] in women, and from respiratory diseases in men [CI(90%) -39% to -4%], while it was greater for breast cancer in women [CI(90%) 2% to 28%] within the 2 km buffer.

CONCLUSIONS

Analysis of mortality by census sections is a helpful exploratory tool for investigating environmental risk factors and directing actions to sites and risk factors with a greater impact on health. Further epidemiological and environmental investigations around metal-processing and energy-producing plants are required.

Is there much variation in variation? Revisiting statistics of small area variation in health services research

Background

The importance of Small Area Variation Analysis for policy-making contrasts with the scarcity of work on the validity of the statistics used in these studies. Our study aims at 1) determining whether variation in utilization rates between health areas is higher than would be expected by chance, 2) estimating the statistical power of the variation statistics; and 3) evaluating the ability of different statistics to compare the variability among different procedures regardless of their rates.

Methods

Parametric bootstrap techniques were used to derive the empirical distribution for each statistic under the hypothesis of homogeneity across areas. Non-parametric procedures were used to analyze the empirical distribution for the observed statistics and compare the results in six situations (low/medium/high utilization rates and low/high variability). A small scale simulation study was conducted to assess the capacity of each statistic to discriminate between different scenarios with different degrees of variation.

Results

Bootstrap techniques proved to be good at quantifying the difference between the null hypothesis and the variation observed in each situation, and to construct reliable tests and confidence intervals for each of the variation statistics analyzed. Although the good performance of Systematic Component of Variation (SCV), Empirical Bayes (EB) statistic shows better behaviour under the null hypothesis, it is able to detect variability if present, it is not influenced by the procedure rate and it is best able to discriminate between different degrees of heterogeneity.

Conclusion

The EB statistics seems to be a good alternative to more conventional statistics used in small-area variation analysis in health service research because of its robustness.

Risk of cognitive impairment in female premutation carriers of fragile X premutation: analysis by means of robust segmented linear regression models

This report describes a study focused on the relationship between CGG repeat length, FMRP, mRNA levels and cognitive functioning in premutation carriers (PM) carriers of Fragile X Syndrome (FXS). We studied 60 females-43 with PM and 17 with normal (N) alleles-from 25 FXS Spanish families. The Wechsler scales were administered to all subjects and new blood samples and hair roots were taken to study mRNA and FMRP levels. Using lowess curves together with segmented models we showed that within the premutation range, IQ scores tend to decrease when the number of CGG repeats increases and the FMRP values decrease. Furthermore, we discovered cut-off points in the molecular variables that seem to change the probability of having some cognitive impairment. Specifically, for those PM females in the upper premutation range (CGG > or = 100) and with FMRP expression < 60% in hair roots, a 10% decrement of FMRP expression represents a significant decrease in IQ scores of about six points, which is more evident for Full-Scale IQ (P-value = 0.035) and Performance IQ (P-value = 0.045) than for Verbal IQ (P-value = 0.074). On the contrary, we did not find any significant correlation between FMR1 mRNA levels and the IQ scores, probably due to the fact that mRNA levels were measured in blood. In conclusion, our findings suggest that the PM can have some effect on cognitive ability in female carriers, although these effects may be subtle. In these cases, it would be advisable to carry out a hair root analysis of FMRP.

Cognitive function in facioscapulohumeral dystrophy correlates with the molecular defect

Previous studies based on case descriptions and neuroradiological findings have suggested central nervous system (CNS) involvement in facioscapulohumeral dystrophy. The aim of this work is to explore the relationship between cognitive/personality pattern and the underlying molecular defect for this muscular dystrophy. We performed a wide-ranging neuropsychological assessment of 34 molecularly confirmed facioscapulohumeral dystrophy patients and 49 control subjects, all of whom also received the Millon-II Multiaxial Clinical Inventory (MCMI-II). Patients and controls show mild learning-level differences in the neuropsychological profile, and only the hysteriform scale is statistically higher in patients than controls. The patients' intelligence quotient (IQ) is related to the size of the deleted fragment but not to the degree of muscular impairment. The results of this study indicate a cut-off point and two distinct cognitive profiles in facioscapulohumeral dystrophy, depending on the patients' molecular defect: patients with a fragment size > 24 kb show a relatively normal cognitive pattern, whereas those with a fragment size < or = 24 kb show a significantly reduced IQ and difficulties with verbal function and visuo-constructive tasks. This work provides more evidence for the involvement of the CNS in facioscapulohumeral dystrophy and suggests that the fragment size should be taken into account in the clinical management of facioscapulohumeral dystrophy as it has a predictive value on the cognitive phenotype.

Impact of cannabis and other drugs on age at onset of psychosis

OBJECTIVE

The aim of this study was to investigate the relationship between age and cannabis use in patients with a first psychotic episode, and to analyze the mediating effect of comorbid use of other drugs and sex on age at onset of psychosis.

METHOD

All consenting patients (aged 15 to 65 years) with a first psychotic episode needing inpatient psychiatric treatment during a 2-year period between February 1997 and January 1999 were considered, confirming a total of 131 patients. Subjects were interviewed using the Structured Clinical Interview for DSM-IV Axis I Disorders, and clinical and demographic data were collected. We used general linear models with age at onset as the response variable and survival Cox models to confirm the results. Both a multivariate linear model and the corresponding Cox model were fitted with a covariate that summarizes the most significant contributors that seemed to decrease age at onset.

RESULTS

Regarding the effect of cannabis use, a significant gradual reduction on age at onset was found as dependence on cannabis increased, consisting in a decrement of 7, 8.5, and 12 years for users, abusers, and dependents, respectively, with respect to nonusers (p = .004, p < .001, and p < .001, respectively). Multivariate analysis showed a clear effect of cannabis use on age at onset, which was not explained by the use of other drugs or by gender. The finding was similar in the youngest patients, suggesting that this effect was not due to chance.

CONCLUSION

The major contribution of this investigation is the independent and strong link between cannabis use and early age at onset of psychosis, and the slight or nonexistent effect of sex and comorbid substance abuse in this variable. These results point to cannabis as a dangerous drug in young people at risk of developing psychosis.

Analysis of FMR1 gene expression in female premutation carriers using robust segmented linear regression models

Fragile X syndrome is caused by the absence or reduction of the fragile X mental retardation protein (FMRP) because FMR1 gene expression is reduced. Alleles with repeat sizes of 55-200 are classified as premutations, and it has been demonstrated that FMR1 expression is elevated in the premutation range. However, the majority of the studies reported were performed in males. We studied FMR1 expression in 100 female fragile X family members from the northern region of Spain using quantitative (fluorescence) real-time polymerase chain reaction. Of these 100 women, 19 had normal alleles, 19 were full mutation carriers, and 62 were premutation carriers. After confirming differences between the three groups of females, and increased levels of the FMR1 transcript among premutation carriers, we found that the relationship between mRNA levels and repeat size is nonlinear. These results were obtained using a novel methodology that, based on the size of the CGG repeats, allows us to find out the most probable threshold from which the relationship between CGG repeat number and mRNA levels changes. Using this approach, a significant positive correlation between CGG repeats and total mRNA levels has been found in the premutation range <100 CGG, but this correlation diminishes from 100 onward. However, when correcting by the X inactivation ratio, mRNA levels increase as the number of CGG repeats increases, and this increase is highly significant over 100 CGG. We suggest that due to skewed X inactivation, mRNA levels tend to normalize in females when the number of CGG repeats increases.

Analysis of latent tuberculosis and mycobacterium avium infection data using mixture models

BACKGROUND

Estimation of the frequency of latent tuberculosis infection (LTBI) is difficult in areas with low tuberculosis infection rates and high exposure to non-tuberculous mycobacteria (NTM), including BCG vaccination. The objective was to assess LTBI and M avium infection and to estimate their probability based on skin tests responses in an infant population from a region with the aforementioned characteristics.

METHODS

A population-based tuberculin skin test (TST) and sensitin (M avium) survey was conducted on seven years old infants in Biscay, a province from The Basque Country (Spain). 2268 schoolchildren received sensitin and 5277 TST. Participation rate was 89%. Commonly used estimation methods were compared with a method based on the fit of mixture models using the Expectation Maximization algorithm. Functions estimating the probabilities of LTBI and M avium infection given the observed skin tests responses were developed for vaccinated and unvaccinated children.

RESULTS

LTBI prevalences varied widely according to the estimation method. The mixture model provided prevalences higher than expected although intermediates between those obtained by currently recommended approaches. Exposure to previous BCG vaccine produces an upward shift of an average of about 3 mm on the induration size to attain the same probability of infection.

CONCLUSION

Our results confirm the commonplace exposure to NTM which effect should be taken into account when performing and assessing tuberculin surveys. The use of mixture analysis under the empirical Bayes framework allows to better estimate the probability of LTBI in settings with presence of other NTM and high BCG-vaccination coverage. An estimation of the average effect of BCG vaccination on TST induration is also provided. These models maximise information coming from classical tuberculin surveys and could be used together with the newly developed blood tests to improve survey's specificity and cost-effectiveness.

Modelling risks in disease mapping

In this article, we propose a strategy of analysis of mortality data with the aim of providing a guideline for epidemiologists and public health researchers to choose a reasonable model for estimating mortality (or incidence) risks. Maps displaying the crude mortality rates or ratios are usually misleading because of the instability of the estimators in low populated areas. As an alternative, many smoothing methods have been presented in the literature based on Poisson inference. They account for the extra-Poisson variation (overdispersion), frequently present in the homogeneous Poisson model, by incorporating random effects. Here, we recommend to test for the potential sources of extra-Poisson variation because, depending on them, the models which fit better the data may be different. Overdispersion can be mainly due to spatial autocorrelation, unstructured heterogeneity or to a combination of these two, and also, when studying very rare diseases, it can be due to an excess of zeros in the data. In this article, different situations the analyst may encounter are detailed and appropriate procedures for each case are presented. The alternative models are illustrated using mortality data provided by the Statistical Institute of Navarra, Spain.

A cohort study to estimate occupational mortality risks in Navarra

BACKGROUND

Few studies on occupational mortality have been conducted in Spain. The objective of this work was to analyse inequalities on global mortality and on mortality due to specific causes according to occupation in a historical cohort of males from the province of Navarra, Spain.

METHODS

The base population for this historical cohort comprised all employed men over age 34 from Navarra in the 1986 population register. Age-standardised point estimates and confidence intervals for occupational-specific mortality risks were computed.

RESULTS

There exist differences in mortality risks with respect to the overall risk of Navarra in certain occupational activities for several major causes of mortality. Some of the results corroborate previous findings in other works, such as the significant high risk that presents in leather, clothing workers and shoemakers when analysing kidney, bladder and other urinary malignant tumours, while others present a certain degree of novelty.

CONCLUSION

This work contributes to filling the gap in the lack of works on occupational mortality in Spain. It also complements the information that other monitoring systems may provide on occupational health.